Signature Form

You must sign and Submit this form to become a patient.

This is a signature page which will be scanned into your chart. By completing these sections and signing below, you acknowledge that you have read and understood all associated forms. We created this form to make it easier for patients to complete the paperwork and to save paper. The forms you are asked to sign are standard and required by law disclosure statements. If you disagree with, or do not clearly understand any of the forms you should not sign at the bottom of this page, and you could not be automatically enrolled as a patient in our practice. In such a case, please call us to discuss your concerns.

STANDARD AUTHORIZATION OF USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Person #1 Name

First Name

Last Name

Phone

(###)

###

####

Relationship

Person # 2 Name

First Name

Last Name

Phone

(###)

###

####

Relationship

Person #3

First Name

Last Name

Phone

(###)

###

####

Relationship

I have read and understood the HIPAA Notice of Privacy Practices and Financial Responsibility form *

required to complete form

I have read and understood the Informed Consent to Telemedicine Consultation form *

required to complete form

I have read and understood the Advanced Beneficiary Note and Pathology Lab Service Agreement form *

required to complete form

I have read and understood the Standard Authorization of Use and Disclosure and Cancelation Policy Form *

required to complete form

Date

YYYY

Print Name

First Name

Last Name

Signature Form

Our Office